| Hashimoto's thyroiditis |
| Classification and external resources |
| ICD-10 |
E06.3 |
| ICD-9 |
245.2 |
| OMIM |
140300 |
| DiseasesDB |
5649 |
| MedlinePlus |
000371 |
| eMedicine |
med/949 |
| MeSH |
D050031 |
Hashimoto's thyroiditis or chronic lymphocytic thyroiditis is an autoimmune disease in which the thyroid gland is attacked by a variety of cell- and antibody-mediated immune processes. It was the first disease to be recognized as an autoimmune disease.[1] It was first described by the Japanese specialist Hakaru Hashimoto in Germany in 1912.
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Contents
- 1 Signs and symptoms
- 2 Diagnosis
- 3 Risk factors
- 4 Mechanisms and pathology
- 5 Treatment
- 6 Prognosis
- 7 Epidemiology
- 8 History
- 9 See also
- 10 References
- 11 External links
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Signs and symptoms
Hashimoto's thyroiditis very often results in hypothyroidism with bouts of hyperthyroidism. Symptoms of Hashimoto's thyroiditis include Myxedematous psychosis, weight gain, depression, mania, sensitivity to heat and cold, paresthesia, fatigue, panic attacks, bradycardia, tachycardia, high cholesterol, reactive hypoglycemia, constipation, migraines, muscle weakness, cramps, memory loss, infertility and hair loss.
The thyroid gland may become firm, large, and lobulated in Hashimoto's thyroiditis, but changes in the thyroid can also be nonpalpable.[2] Enlargement of the thyroid is due to lymphocytic infiltration and fibrosis rather than tissue hypertrophy. Physiologically, antibodies against thyroid peroxidase (TPO) and/or thyroglobulin cause gradual destruction of follicles in the thyroid gland. Accordingly, the disease can be detected clinically by looking for these antibodies in the blood. It is also characterized by invasion of the thyroid tissue by leukocytes, mainly T-lymphocytes. It is associated with non-Hodgkin lymphoma.
Diagnosis
Diagnosis is made by detecting elevated levels of anti-thyroid peroxidase antibodies in the serum.
Given the relatively non-specific symptoms of initial hypothyroidism, Hashimoto's thyroiditis is often misdiagnosed as depression, cyclothymia, PMS, chronic fatigue syndrome, fibromyalgia and, less frequently, as ED or an anxiety disorder. On gross examination, there is often presentation of a hard goitre that is not painful to the touch;[3] other symptoms seen with hypothyroidism, such as periorbital myxedema, depends on the current state of progression of the response, especially given the usually gradual development of clinically relevant hypothyroidism. Testing for thyroid-stimulating hormone (TSH), Free T3, Free T4, and the anti-thyroglobulin antibodies (anti-Tg), anti-thyroid peroxidase antibodies (anti-TPO) and anti-microsomal antibodies can help obtain an accurate diagnosis.[4] Earlier assessment of the patient may present with elevated levels of thyroglobulin owing to the transient thyrotoxicosis as inflammation within the thyroid causes damage to the integrity of thyroid follicle storage of thyroglobulin; TSH is concomitantly decreased.[5]
Ultrasound imaging of the thyroid gland (right lobe longitudinal) in patient with Hashimoto Thyroiditis.
This exposure of the body to substantial amounts of previously isolated thyroid enzymes is thought to contribute to the exacerbation of tolerance breakdown giving rise to the more pronounced symptoms seen later in the disease as thyroperoxidase and thyroglobulin are further exposed to without. Lymphocytic infiltration of the thyrocyte-associated tissues often leads to the histologically significant finding of germinal center development within the thyroid gland.
Hashimoto's when presenting as mania is known as Prasad's syndrome after Ashok Prasad, the psychiatrist who first described it.[6]
Risk factors
A family history of thyroid disorders is common, with the HLA-DR5 gene most strongly implicated conferring a relative risk of 3 in the UK. In addition Hashimoto's thyroiditis may be associated with CTLA-4(Cytotoxic T-lymphocyte Associated-4) gene polymorphisms that result in reduced functioning of the gene's products, which are associated with negative regulation of T-lymphocyte activity.[7] Downregulatory gene polymorphisms affecting CTLA4 are also associated with autoimmune pathology seen in development of Type I diabetes.[8] The strong genetic component underscoring this theory is borne out in studies on monozygotic twins, with a concordance of 38-55%, with an even higher concordance of circulating thyroid antibodies not in relation to clinical presentation (up to 80% in monozygotic twins). Neither result was seen to a similar degree in dizygotic twins, offering strong favour for high genetic aetiology.[9]
Preventable environmental factors, including high iodine intake, selenium deficiency, and pollutants such as tobacco smoke, as well as infectious diseases and certain drugs, have been implicated in the development of autoimmune thyroid disease in genetically predisposed individuals.[10] The genes implicated vary in different ethnic groups and the incidence is increased in patients with chromosomal disorders, including Turner, Down's, and Klinefelter syndromes usually associated with autoantibodies against thyroglobulin and thyroperoxidase. Progressive depletion of these cells as the cytotoxic immune response develops leads to higher degrees of primary hypothyroidism, presenting with a poverty of T3/T4 levels, and compensatory elevations of TSH.
Mechanisms and pathology
There are multiple suggested mechanisms by which the pathology of Hashimoto's Thyroiditis develops. Various autoantibodies may be present against thyroid peroxidase, thyroglobulin and TSH receptors, although a small percentage of patients may have none of these antibodies present. As indicated in various twin studies a percentage of the population may also have these antibodies without developing Hashimoto's thyroiditis. Nevertheless, antibody-dependent cell-mediated cytotoxicity is a substantial factor behind the apoptotic fall-out of Hashimoto's thyroiditis. Activation of cytotoxic T-lymphocytes (CD8+ T-cells) in response to cell-mediated immune response affected by helper T-lymphocytes (CD4+ T-cells) is central to thyrocyte destruction. As is characteristic of type IV hypersensitivities, recruitment of macrophages is another effect of the helper T-lymphocyte activation, with Th1 axis lymphocytes producing inflammatory cytokines within thyroid tissue to further macrophage activation and migration into the thyroid gland for direct effect.
Gross morphological changes within the thyroid are seen in the general enlargement which is far more locally nodular and irregular than more diffuse patterns (such as that of hyperthyroidism). While the capsule is intact and the gland itself is still distinct from surrounding tissue, microscopic examination can provide a more revealing indication of the level of damage.[3]
Histologically, the hypersensitivity is seen as diffuse parenchymal infiltration by lymphocytes, particularly plasma B-cells, which can often be seen as secondary lymphoid follicles (germinal centers, not to be confused with the normally present colloid-filled follicles that constitute the thyroid). Atrophy of the colloid bodies is lined by Hürthle cells, cells with intensely eosinophilic, granular cytoplasm, a metaplasia from the normal cuboidal cells that constitute the lining of the thyroid follicles. Severe thyroid atrophy presents often with denser fibrotic bands of collagen that remains within the confines of the thyroid capsule.[11]
Treatment
Hypothyroidism caused by Hashimoto's Thyroiditis is treated with thyroid hormone replacement agents such as levothyroxine or desiccated thyroid extract. A tablet taken once a day generally keeps the thyroid hormone levels normal. In most cases, the treatment needs to be taken for the rest of the patient's life. In the event that hypothyroidism is caused by Hashimoto's Thyroiditis, it is recommended that the TSH levels be kept under 3.0.[12] As long as the patient's thyroid is active, the body will continue to attack it, and this can wreak havoc on the patient's TSH levels and symptoms.
Preliminary studies have suggested a correlation between Hashimoto's Thyroiditis and Celiac sprue.[13] While it has not been rigorously explored, there is anecdotal evidence that a gluten-free diet may reduce the autoimmune response responsible for thyroid degeneration.[14] A study published in January 2012 compared a group of confirmed Celiac's patients to a control group of healthy individuals, starting a gluten-free diet and continuing for one year.[15] While there was a higher occurrence of thyroiditis found amongst the Celiac group, there was no reduction in their level of anti-TPO antibody, improvement in thyroid function, or change in thyroid volume reduction after one year without gluten. The study mentions that its results disagree with other reports.
Prognosis
If untreated for an extended period, Hashimoto's thyroiditis may lead to muscle failure, including possible heart failure. An extremely rare condition associated with the thyroiditis is Hashimoto's encephalopathy. Although it is well-accepted that Hashimoto's thyroiditis does not cause Hashimoto's encephalopathy, those with Hashimoto's encephalopathy are virtually always eventually diagnosed with Hashimoto's thyroiditis.[16][17]
A rare association is with lymphoma of the thyroid gland. Hashitoxicosis resulting from Hashimoto's has also been reported in a case of acquired von Willebrand's Syndrome and Pernicious Anemia. [18]
Hashimoto's thyroiditis can disrupt growth in children and adolescents and therefore requires close growth monitoring. Growth hormone therapy may be required if the patient's stature is extreme enough.
Epidemiology
This disorder is believed to be the most common cause of primary hypothyroidism in North America; as a cause of non-endemic goiter, it is among the most common.[19] An average of 1 to 1.5 in a 1000 people have this disease.[19] It occurs far more often in women than in men (between 10:1 and 20:1), and is most prevalent between 45 and 65 years of age.[19] Occurrence in children is also not uncommon, especially in populations wherein iodine is a dietary scarcity, Hashimoto's is a major cause of goiter.[19]
In European countries, an atrophic form of autoimmune thyroiditis (Ord's thyroiditis) is more common than Hashimoto's thyroiditis.
History
The explanation board of
Hashimoto Dōri in Kyushu University
Also known as Hashimoto's disease, Hashimoto's thyroiditis is named after the Japanese physician Hakaru Hashimoto (1881−1934) of the medical school at Kyushu University,[20] who first described the symptoms of patients with struma lymphomatosa, an intense infiltration of lymphocytes within the thyroid, in 1912 in a German publication.[21] The report gave new insight into a condition (hypothyroidism) more commonly seen in areas of iodine deficiency that was occurring in the developed world, and without evident causation by dietary deficiency.
See also
- Thyroid gland
- Thyroid lymphoma
- Myxedematous psychosis
- Autoimmune thyroiditis
References
- ^ Nakazawa, Donna (2008). The Autoimmune Epidemic. New York: Simon & Schuster. pp. 32–35. ISBN 978-0-7432-7775-4.
- ^ Page 56 in: Staecker, Hinrich; Thomas R. Van De Water; Van de Water, Thomas R. (2006). Otolaryngology: basic science and clinical review. Stuttgart: Thieme. ISBN 0-86577-901-5.
- ^ a b Kumar, Vinay (2010). "24: The Endocrine System". Robbins and Cotran Pathologic Mechanisms of Disease (8th ed.). Philidelphia, PA: Elsevier. p. 1113.
- ^ Giannini, AJ (1986). The Biological Foundations of Clinical Psychiatry. New Hyde Park, NY: Medical Examination Publishing Company. pp. 193–198. ISBN 0-87488-449-7.
- ^ Simmons, PJ; Dellemarre, FG., Drexhage, HA. (July 1998). "Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6". Endocrinology 139 (7): 3158–3186. doi:10.1210/en.139.7.3148. PMID 9645688.
- ^ "Prasad's syndrome" (PDF). http://bjp.rcpsych.org/cgi/reprint/152/3/438b?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=weiner+kennedy&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT.
- ^ Kavvoura, F. K.; Akamizu, T.; Awata, T.; Ban, Y.; Chistiakov, D. A.; Frydecka, I.; Ghaderi, A.; Gough, S. C. et al. (2007). "Cytotoxic T-Lymphocyte Associated Antigen 4 Gene Polymorphisms and Autoimmune Thyroid Disease: A Meta-Analysis". Journal of Clinical Endocrinology & Metabolism 92 (8): 3162–70. doi:10.1210/jc.2007-0147. PMID 17504905.
- ^ Jacobson, Eric M.; Tomer, Yaron (2007). "The CD40, CTLA-4, thyroglobulin, TSH receptor, and PTPN22 gene quintet and its contribution to thyroid autoimmunity: Back to the future". Journal of Autoimmunity 28 (2–3): 85–98. doi:10.1016/j.jaut.2007.02.006. PMC 2043086. PMID 17369021. //www.ncbi.nlm.nih.gov/pmc/articles/PMC2043086/.
- ^ Chistiakov, Dimitry A (2005). "Immunogenetics of Hashimoto's thyroiditis". Journal of Autoimmune Diseases 2 (1): 1. doi:10.1186/1740-2557-2-1. PMC 555850. PMID 15762980. //www.ncbi.nlm.nih.gov/pmc/articles/PMC555850/.
- ^ Saranac, L.; Zivanovic, S.; Bjelakovic, B.; Stamenkovic, H.; Novak, M.; Kamenov, B. (2011). "Why is the Thyroid So Prone to Autoimmune Disease". Hormone Research in Paediatrics 75 (3): 157–65. doi:10.1159/000324442. PMID 21346360.
- ^ Kumar, Vinay (2010). "24: The Endocrine System". Robbins and Cotran Pathologic Mechanisms of Disease (8th ed.). Philidelphia, PA: Elsevier. pp. 1112–1113.
- ^ "Does Your Doctor Know About the New TSH Lab Standards?". http://thyroid.about.com/cs/testsforthyroid/a/labs2003.htm.
- ^ "Connection Found Between Celiac Disease and Hashimoto's Thyroiditis". http://www.celiac.com/articles/1135/1/Connection-Found-between-Celiac-Disease-and-Hashimotos-Thyroiditis/Page1.html.
- ^ "Wendy vs. Autoimmune Hypothyroid". http://wendyvshypothyroid.blogspot.com/.[unreliable medical source?]
- ^ Metso, Saara; Hyytiä-Ilmonen, Henni; Kaukinen, Katri; Huhtala, Heini; Jaatinen, Pia; Salmi, Jorma; Taurio, Jyrki; Collin, Pekka (2012). "Gluten-free diet and autoimmune thyroiditis in patients with celiac disease. A prospective controlled study". Scandinavian Journal of Gastroenterology 47 (1): 43–8. doi:10.3109/00365521.2011.639084. PMID 22126672.
- ^ http://archneur.jamanetwork.com/article.aspx?articleid=790539
- ^ http://henotebook.wordpress.com/case-studies/
- ^ https://www.researchgate.net/publication/20485667_Acquired_von_Willebrand_syndrome_associated_with_Hashitoxicosis_and_pernicious_anemia_combined.
- ^ a b c d Kumar, Vinay (2010). "24: The Endocrine System". Robbins and Cotran Pathologic Mechanisms of Disease (8th ed.). Philidelphia, PA: Elsevier. pp. 1111–205.
- ^ Hakaru Hashimoto at Who Named It?
- ^ Hashimoto, H. (1912). "Zur Kenntnis der lymphomatösen Veränderung der Schilddrüse (Struma lymphomatosa)". Archiv für klinische Chirurgie (Berlin) 97: 219–248.
External links
- Hashimoto's disease at the Mayo Clinic
- Sasaki, N; Takahashi, A; Nakano, N; Saito, T (2001). "A case of 'hallucination of soliloquy' with hypothyroidism induced Hashimoto disease. Meaning of psychopathological research about symptomatic psychosis". Seishin shinkeigaku zasshi 103 (2): 185–96. PMID 11326441.
- Hall, Richard C.W.; Popkin, Michael K.; Devaul, Richard; Hall, Anne K.; Gardner, Earl R.; Beresford, Thomas P. (April 1986). "Psychiatric manifestations of Hashimoto's thyroiditis". Psychosomatics 23 (4): 337–42. doi:10.1016/S0033-3182(82)73397-3. PMID 6896238. http://psy.psychiatryonline.org/cgi/reprint/23/4/337.pdf.
Up to Date List of Case Studies and Research on Hashimoto's Encephalopathy - [1]
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Endocrine pathology: endocrine diseases (E00–E35, 240–259)
|
|
Pancreas/
glucose
metabolism |
| Hypofunction |
- types:
- type 1
- type 2
- MODY 1 2 3 4 5 6
- complications
- coma
- angiopathy
- ketoacidosis
- nephropathy
- neuropathy
- retinopathy
- cardiomyopathy
- insulin receptor (Rabson–Mendenhall syndrome)
- Insulin resistance
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| Hyperfunction |
- Hypoglycemia
- beta cell (Hyperinsulinism)
- G cell (Zollinger–Ellison syndrome)
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|
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Hypothalamic/
pituitary axes |
| Hypothalamus |
- gonadotropin
- Kallmann syndrome
- Adiposogenital dystrophy
- CRH (Tertiary adrenal insufficiency)
- vasopressin (Neurogenic diabetes insipidus)
- general (Hypothalamic hamartoma)
|
|
| Pituitary |
| Hyperpituitarism |
- anterior
- Acromegaly
- Hyperprolactinaemia
- Pituitary ACTH hypersecretion
- posterior (SIADH)
- general (Nelson's syndrome)
|
|
| Hypopituitarism |
- anterior
- Kallmann syndrome
- Growth hormone deficiency
- ACTH deficiency/Secondary adrenal insufficiency
- GnRH insensitivity
- FSH insensitivity
- LH/hCG insensitivity
- posterior (Neurogenic diabetes insipidus)
- general
- Empty sella syndrome
- Pituitary apoplexy
- Sheehan's syndrome
- Lymphocytic hypophysitis
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|
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| Thyroid |
| Hypothyroidism |
- Iodine deficiency
- Cretinism
- Congenital hypothyroidism
- Myxedema
- Euthyroid sick syndrome
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| Hyperthyroidism |
- Hyperthyroxinemia
- Thyroid hormone resistance
- Familial dysalbuminemic hyperthyroxinemia
- Hashitoxicosis
- Thyrotoxicosis factitia
- Graves' disease
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| Thyroiditis |
- Acute infectious
- Subacute
- De Quervain's
- Subacute lymphocytic
- Autoimmune/chronic
- Hashimoto's
- Postpartum
- Riedel's
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| Goitre |
- Endemic goitre
- Toxic nodular goitre
- Toxic multinodular goiter
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| Parathyroid |
| Hypoparathyroidism |
- Hypoparathyroidism
- Pseudohypoparathyroidism
- Pseudopseudohypoparathyroidism
|
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| Hyperparathyroidism |
- Primary
- Secondary
- Tertiary
- Osteitis fibrosa cystica
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|
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| Adrenal |
| Hyperfunction |
- aldosterone: Hyperaldosteronism/Primary aldosteronism
- Conn syndrome
- Bartter syndrome
- Glucocorticoid remediable aldosteronism
- AME
- Liddle's syndrome
- 17α CAH
- cortisol: Cushing's syndrome (Pseudo-Cushing's syndrome)
- sex hormones: 21α CAH
- 11β CAH
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Hypofunction/
Adrenal insufficiency
(Addison's, WF) |
- aldosterone: Hypoaldosteronism
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|
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| Gonads |
- ovarian: Polycystic ovary syndrome
- Premature ovarian failure
- testicular: enzymatic
- 5α-reductase deficiency
- 17β-hydroxysteroid dehydrogenase deficiency
- aromatase excess syndrome)
- Androgen receptor (Androgen insensitivity syndrome
- general: Hypogonadism (Delayed puberty)
- Hypergonadism
- Hypoandrogenism
- Hypoestrogenism
- Hyperandrogenism
- Hyperestrogenism
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| Height |
- Dwarfism/Short stature
- Laron syndrome
- Psychosocial
- Gigantism
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| Multiple |
- Autoimmune polyendocrine syndrome
- Carcinoid syndrome
- Multiple endocrine neoplasia
- Progeria
- Werner syndrome
- Acrogeria
- Metageria
- Woodhouse-Sakati syndrome
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noco (d)/cong/tumr, sysi/epon
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proc, drug (A10/H1/H2/H3/H5)
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Immune disorders: hypersensitivity and autoimmune diseases (279.5–6)
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Type I/allergy/atopy
(IgE) |
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Foreign
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Atopic dermatitis · Allergic urticaria · Hay fever · Allergic asthma · Anaphylaxis · Food allergy (Milk, Egg, Peanut, Tree nut, Seafood, Soy, Wheat), Penicillin allergy
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Autoimmune
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none
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Type II/ADCC
(IgM, IgG) |
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Foreign
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Pernicious anemia · Hemolytic disease of the newborn
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Autoimmune
|
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Cytotoxic
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Autoimmune hemolytic anemia · Idiopathic thrombocytopenic purpura · Bullous pemphigoid · Pemphigus vulgaris · Rheumatic fever · Goodpasture's syndrome
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"Type 5"/receptor
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Graves' disease · Myasthenia gravis
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Type III
(Immune complex) |
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Foreign
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Henoch–Schönlein purpura · Hypersensitivity vasculitis · Reactive arthritis · Farmer's lung · Post-streptococcal glomerulonephritis · Serum sickness · Arthus reaction
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Autoimmune
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Systemic lupus erythematosus · Subacute bacterial endocarditis · Rheumatoid arthritis
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Type IV/cell-mediated
(T-cells) |
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Foreign
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Allergic contact dermatitis · Mantoux test
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Autoimmune
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Diabetes mellitus type 1 · Hashimoto's thyroiditis · Guillain–Barré syndrome · Multiple sclerosis · Coeliac disease · Giant-cell arteritis
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GVHD
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Transfusion-associated graft versus host disease
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Unknown/
multiple |
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Foreign
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Hypersensitivity pneumonitis (Allergic bronchopulmonary aspergillosis) · Transplant rejection · Latex allergy (I+IV)
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Autoimmune
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Sjögren's syndrome · Autoimmune hepatitis · Autoimmune polyendocrine syndrome (APS1, APS2) · Autoimmune adrenalitis · Systemic autoimmune disease
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cell/phys/auag/auab/comp, igrc
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